Drink ice-cold water ("your body has to burn calories to keep your temperature up") and hot water with bullion cubes ("only 5 calories a cube, and they taste wonderful"). When a food craving strikes, give yourself a manicure ("applying extra layers of slow-drying polish. It will keep your hands occupied"). These kinds of tips are common fare in the growing world of "pro-ana" (pro-anorexia) and "pro-mia" (pro-bulimia) Web sites. More than 200 such sites now cater to the estimated .5 to 1 percent of adolescent and adult women who are anorexic and to the 1 to 2 percent who are bulimic.
Well intended or not, the sites are "not benign," says Dr. Rebecka Peebles, a specialist in adolescent medicine at Stanford University's Lucile Packard Children's Hospital. In "Surfing for Thinness: A Pilot Study of Pro-Eating Disorder Web Site Usage in Adolescents with Eating Disorders," published this week in Pediatrics, the journal of the American Academy of Pediatrics, she and her colleagues reported the results of a survey of eating-disorder patients and their parents. They found that patients who used pro-eating-disorder sites were sick longer and spent less time doing schoolwork. Patients who used both pro-eating-disorder and pro-recovery sites were admitted to the hospital more times than nonusers.
Many experts find the pro-eating-disorder sites appalling. "It's one of the few times in history that someone has come out and said that a very dangerous illness is a good idea, and here's how to do it," says Christopher Athas, vice president of the National Association of Anorexia Nervosa and Associated Disorders. "They talk about First Amendment rights. But this is like shouting fire ... These people with these sites claim that they are representing a lifestyle, but they are representing a dangerous illness." Researchers have demonstrated that eating disorders can lead to anxiety, depression, alcoholism, substance abuse, self-mutilation and suicide.
But the pro-ana and pro-mia sites, which the study says are more numerous than pro-recovery sites, tend to gloss over that kind of information—and the fact that people with anorexia are more than 56 times more likely than their peers to commit suicide, says Cynthia Bulik, director of the eating-disorders program at the University of North Carolina at Chapel Hill. "People who are posting to these sites are accomplices to suicide."
Such sites can interfere with treatment, especially during the first year, when anorexics are at high risk for relapse, says Bulik. "It's a high-risk cue, or a trigger," she says. "I don't think anorexia nervosa is an addiction, but these sites have the ability to pull them into something that's familiar and comfortable. You want your supportive treatment team to be the strong voice in your head."
The pro-eating-disorder Web sites are a "seductive" alternative, says Bulik. Pro-ana-nation.com, for example, which NEWSWEEK visited, tells viewers, "If you have lived with an eating disorder for years and not been able to recover, you have found a place where you will not be judged." The site includes postings such as, "I can't eat without feeling guilty unless it's like a grape." Like some of the sites, pro-ana-nation.com also notes many health problems associated with anorexia nervosa, including skin that gets dry, yellows and becomes covered with soft hair.
The study found that eating-disorder patients can get new, often harmful ideas from pro-ana and pro-mia sites. Researchers report that 96 percent of respondents who visited pro-eating-disorder sites said they learned new weight-loss or purging techniques; so did 46 percent of respondents who visited pro-recovery sites. Seven out of 10 users of pro-eating-disorder sites said they used the new techniques they learned; a third used new diet pills, supplements or laxatives. Parents had little knowledge of their teens' visits to these sites.
To conduct the study, Stanford researchers sent anonymous surveys to 698 families of patients, ages 10 to 22, treated for an eating disorder by the Adolescent Medicine Division at Stanford between 1997 and 2004. Respondents included 76 patients and 106 parents. Of the patients, 35.5 percent reported visiting pro-eating-disorder sites, defined in the study as "communities of individuals who engage in disordered eating and use the internet to discuss their activities." Also, 41 percent said they went to pro-recovery sites, which the study describe as having "a recovery-oriented perspective." And 25 percent visited both ,while 48.7 percent visited neither. It's not surprising that anorexics may visit both pro-eating-disorder and pro-recovery sites, says Peebles. "Part of them wants to get better and part wants to stay sick."
Pro-ana and pro-mia sites deny being harmful, saying they provide a community for those with eating disorders. (The term "pro-ana" is widely used and sites vary.) "Most people that come to our Web site already have an eating disorder, and they're looking for support from other people with eating disorders," says Anna Robbins, a 23-year-old mother of two who owns proana.us, a large pro-anorexia Web site. "It's impossible to get one [an eating disorder] from a Web site." She says she is not promoting anorexia and notes that her site includes a psychiatrist. "We don't want anyone going into the hospital and needing a feeding tube," she says. "I do not show nudity or disgusting images such as emaciated people. I think that would be a trigger to someone who may be thinking about recovery."
Robbins, who carries 89 pounds on her 5-foot frame, thinks "thinspiration" photos of celebrities (and others) are fine. "They see celebrities are just as normal as we are, they suffer the same things we do," she says. After "American Idol" contestant Katharine McPhee said she was bulimic, "a lot of people felt a lot better about themselves—they felt normal," she says. Her site helps girls, she says. "A lot of these girls come out here, and they want to kill themselves. We offer them support, saying it will be OK. Continue going to your doctor, we're still here, we'll talk to you." As a result of her disease, Robbins says she suffers from low blood pressure, a heart murmur and an irregular heartbeat. She also always feels cold and thinks constantly about food.
The sites may show pictures of singer Karen Carpenter and note that she died of anorexia. But in general, they don't focus on bad news—such as the Nov. 14 death of Brazilian model Ana Carolina Reston, 21, who suffered from organ failure brought on by anorexia. At 5-foot-7 and 88 pounds, Reston—who had modeled for Giorgio Armani—reportedly subsisted on tomatoes and apples. And this August another model, Luisel Ramos, 22, of Uruguay, who reportedly consumed little more than lettuce and diet soda, died from heart failure. (Anorexia nervosa patients can suffer from an abnormally low heart rate, dry skin, anemia, kidney dysfunction, cardiovascular problems, changes in brain structure and osteoporosis.) "They don't highlight the negative," says Dina Borzeko, a professor of health communication at Johns Hopkins University. She is studying how to present healthy messages about nutrition and physical activity through the Internet.
Many feature thinspirational photos (from shots of Audrey Hepburn to disturbing pictures of rib-protruding unknowns) and "tips and tricks" for eating less or vomiting. Often the message seems to be that Web-site visitors are in good company. Anorexics.net—which bills itself as a "friendly community" rather than a recovery or pro-ana site—features celebrity photos of luminaries like psychoanalyst Anna Freud ("documented that she struggled with anorexia"), poet Anne Sexton ("has struggled with anorexia and depression"), actress Audrey Hepburn ("103 lbs. at 5'7"), Princess Diana of Wales ("suffered from bulimia for years") and others.
The pro-eating-disorder sites feed into anorexics' competitive nature, says eating-disorder specialist Dr. David S. Rosen, a professor of pediatrics and internal medicine at the University of Michigan. "They're constantly trying to be the sickest, the thinnest, the most unhealthy. If you go to a Web site where people are describing their eating habits, their vomiting practices, if you're in the throes of a serious eating disorder, no matter how that information was intended when it was put out there, it may be a challenge to eat less, to take more diet pills, to weight less. That's where the harm is."
Even if the sites featured more bad news about the disease, Rosen isn't so sure the women would care. "I have lots and lots of patients for whom, even though we talk about serious medical consequences and death, it's not a compelling reason for them to want to change," he says. One stereotypical phrase in the profession: "At least I'll be thin in my coffin." "When the brain has been starved as long as it has been, it doesn't work right any more," says Rosen.
Anorexics are similar to obsessive compulsives, says Rosen. The Internet helps them "indulge that obsessive quality," he says. One college patient has a 60-page scrapbook of thinspirational pictures, poetry and information from Web sites. "Fewer than five" of his patients have had a "meaningful recovery aided by a Web site" whereas "a whole lot more than five" have been "substantively worsened" by them, he says. They may be especially harmful for the growing number of younger children with eating disorders. "They're more impressionable, they're less able to think critically about what they're reading and seeing on these Web sites," he says.
Doctors aren't sure whether the pro-ana and pro-mia sites may trigger eating disorders. "A Web site could take somebody who is flirting with an eating disorder and disordered eating behavior and drive their behavior up to where they develop the thinking," says Rosen. It's like a teen who tries cigarettes. "Nobody thinks they're going to become addicted to tobacco," he says. "All of the sudden, they find they can't stop." Anorexics may start out with simple dieting, which then becomes more extreme and obsessive. "For some people, these Web sites may be one of the forces that drives their behavior further over the line because there is that sense of community, that normalization of behavior," he says.
Could the sites somehow lure a completely healthy girl into becoming an anorexic? "You've still got to have some sort of predisposition," says John Levitt, director of the eating-disorders program at Alexian Brothers Behavioral Health Hospital in Hoffman Estates, Ill. "It's a little bit difficult to believe they went there and were pure." Most patients "don't need the advice," he says. By the time he sees them, they already know the tips and tricks. But, he says, "if you have a predisposition for something, you get reinforcement for it."
In November, the Academy for Eating Disorders issued a warning about the proliferation of sites promoting anorexia and asked government officials and Internet service providers to require warning screens for them. AED president Eric van Furth suggested a statement like "Warning: anorexia nervosa is a potentially deadly illness. The site you are about to enter provides material that may be detrimental to your health." Parents, take note.